Provider Demographics
NPI:1851629810
Name:TERRY, JOHNNY B JR (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:B
Last Name:TERRY
Suffix:JR
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:JOHNNY
Other - Middle Name:B/
Other - Last Name:TERRY
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:25 N WINFIELD RD STE 201
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1379
Mailing Address - Country:US
Mailing Address - Phone:630-933-4480
Mailing Address - Fax:
Practice Address - Street 1:25 N WINFIELD RD STE 201
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1379
Practice Address - Country:US
Practice Address - Phone:630-933-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106081363AS0400X
IL085006972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical